Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's physician regarding an incorrect weight documentation, which led to a misinterpretation of the resident's clinical status. The resident, who had diagnoses including quadriplegia, a recent gastrostomy tube placement, a sacral pressure ulcer, malnutrition, and contractures, was identified as being at nutritional risk with a care plan targeting safe weight gain. On 02/26/25, nursing staff documented a weight of 119.4 pounds for the resident, which was later found to be an error and intended for another resident's record. This incorrect weight was referenced by the physician in a subsequent assessment, leading to the belief that the resident was gaining weight. On 03/11/25, the DON corrected the error by striking out the incorrect weight entry but did not notify the resident's physician of this change. Subsequent weights showed a significant weight loss of 6.6 pounds (5.5%) over a three-week period. The failure to communicate the documentation error and the resident's actual weight trajectory to the physician resulted in a lack of timely physician awareness regarding the resident's nutritional status and weight loss.